Confront the staff member it is not the

Confront the staff member.
It is not the responsibility of the nurse to discipline other staff members.
Encourage the client to report the incident.
This action takes the responsibility away from the nurse who has overheard
the comments.
Document the incident in the client's health record.
The incident should not be documented in the client's health record.
Report the occurrence to the charge nurse.
MY ANSWER

It is the charge nurse and the nurse manager's responsibility to confront the
staff member about the derogatory comments made to the client.
FLAG
A nurse in an outpatient mental health setting is collecting a health history
from a client who is taking paroxetine for depression. The client reports to
the nurse that he also takes herbal supplements. The nurse should advise
the client that which of the following supplements interacts adversely with
paroxetine?
St. John's wort
MY ANSWER
St. John's wort is an herbal preparation that decreases the reuptake of
serotonin. The nurse should advise the client that taking St. John's wort with
another medication that also inhibits the reuptake of serotonin, such as
paroxetine, places the client at risk for serotonin syndrome.
Saw palmetto
Saw palmetto is used to treat benign prostatic hyperplasia. It does not
interact adversely with paroxetine.
Echinacea
Echinacea is used to enhance immune function. It does not interact
adversely with paroxetine.
Ginkgo
Ginkgo is used to relieve pain from peripheral arterial disease. It does not
interact adversely with paroxetine.
A nurse is caring for a client who is experiencing alcohol withdrawal. Which
of the following medications should the nurse administer first? (Click on the
"Exhibit" button below for additional client information. There are three tabs
that contain separate categories of data.)

EXHIBIT
Diazepam 5 mg IV bolus
MY ANSWER
The greatest risk to the client who is experiencing alcohol withdrawal is
seizures, an elevated heart rate, and elevated blood pressure. IV diazepam
acts rapidly to prevent seizures, stabilize vital signs, and decrease the
intensity of withdrawal manifestations.
FLAG
A nurse is obtaining a mental health history from an older adult client. Which
of the following actions should the nurse plan to take?
Raise the pitch of the voice when speaking to the client.
The nurse should use a lower pitch of voice when speaking because older
adult clients are typically able to hear words that are spoken with a lower
pitch.
Begin the interview by explaining the plan of care.
The nurse should begin the interview by asking the client to identify their
needs and concerns. This data is then used to create a personalized plan of
care.
Interview the client in a private setting.
MY ANSWER
The nurse should interview clients in a private place when asking questions
regarding client health.